Br. J. Anaesth.-2002-Dolin-409-23

British Journal of Anaesthesia 89 (3): 409-23 (2002)
Effectiveness of acute postoperative pain management:

I. Evidence from published data
S. J. Dolin1, J. N. Cashman2* and J. M. Bland3
'Pain Clinic, St Richard's Hospital, Chichester PO19 4E, UK. 2Department of Anaesthesia,
St. George's Hospital, London SW17 OQT, UK. 3Department of Public Health Sciences,
St George's Hospital Medical School, London SW17 ORE, UK
^Corresponding author
Background. This review examines the evidence from published data concerning the
incidence of moderate-severe and of severe pain after major surgery, with three analgesic
techniques; intramuscular (i.m.) analgesia, patient controlled analgesia (PCA), and epidural
analgesia.
Results. Different pain measurement tools provided comparable data. When considering a
mixture of three analgesic techniques, the overall mean (95% Cl) incidence of moderate-severe
pain and of severe pain was 29.7 (26.4-33.0)% and 10.9 (8.4-13.4)%, respectively. The overall
mean (95% Cl) incidence of poor pain relief and of fair-to-poor pain relief was 3.5 (2.4-4.6)%
and 19.4 (16.4-22.3)%, respectively. For i.m. analgesia the incidence of moderate-severe pain
was 67.2 (58.1-76.2)% and that of severe pain was 29.1 (18.8-39.4)%. For PCA, the incidence
of moderate-severe pain was 35.8 (31.4-40.2)% and that of severe pain was 10.4 (8.0-12.8)%.
For epidural analgesia the incidence of moderate-severe pain was 20.9 (17.8-24.0)% and that of
severe pain was 7.8 (6.1-9.5)%. The incidence of premature catheter dislodgement was 5.7
(4.0-7.4)%. Over the period 1973-1999 there has been a highly significant (P<0.000l) reduction in the incidence.of moderate-severe pain of 1.9 (1.1-2.7)% per year.
Conclusions. These results suggest that the UK Audit Commission (1997) proposed standards of care might be unachievable using current analgesic techniques. The data may be useful
in setting standards of care for Acute Pain Services.
BrJ Anaesth 2002; 89: 409-23
Keywords: analgesic techniques, intramuscular; analgesia, patient-controlled; anaesthetic
techniques, epidural; pain, postoperative
Accepted for publication: April 18, 2002
The Acute Pain Service is a relatively recent innovation,

developed to improve the management of postoperative
pain.l Among the earliest services were those in Kiel2 and in
Seattle.1 The concept was given impetus in the early 1990s
in the UK by the publication of a joint report by the Royal
Colleges of Surgeons and Anaesthetists3 and in USA by the
publication of protocol for Investment in Health Gain4 such
that 73% of US hospitals had a pain service by 1994,5 whilst
in the UK 88% of hospitals had an established pain service
by 1999.6
There is evidence that pain services affect morbidity and

duration of hospital stay.7 However, despite the vast amount
published on acute pain there have been few if any attempts
to establish standards of care for acute postoperative pain
services, although a number of large audits have been
published. In a brief reference to postoperative pain in 1997
the Audit Commission (UK) proposed a standard whereby
less than 20% of patients should experience severe pain
following surgery after 1997, and that this should ideally
reduce to less than 5% by 2002.8 It is not clear from the
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Methods. A MEDLINE search of the literature was conducted for publications concerned
with the management of postoperative pain. Over 800 original papers and reviews were identified. Of these 212 papers fulfilled the inclusion criteria but only 165 provided usable data on
pain intensity and pain relief. Pooled data on pain scores obtained from these studies, which
represent the experience of a total of nearly 20 000 patients, form the basis of this review.
Effectiveness of postoperative pain management
Audit Commission document how these figures have been

arrived at, nor how valid this standard might be. In the light
of this recommendation we decided to review the published
literature on acute pain management in order to establish the
validity of the Audit Commission's proposed standard.
In the past, pain relief has been provided mainly by 'as
required' intramuscular (i.m.) injections of opioids. More
recently, intravenous (i.v.) patient-controlled analgesia
(PCA) and epidural analgesia have become popular, as
they are perceived as being more effective. However, pain
and pain relief are just one aspect of the wide range of
outcome variables with which pain services are interest. For
a review to be comprehensive it should consider three broad
areas of outcome, such as effectiveness, safety, and
tolerability. Effectiveness can be inferred from pain scores
and pain relief reports. The incidence of respiratory
depression and hypotension may be indicative of the safety
of the techniques whilst tolerability is reflected by the
occurrence of nausea and vomiting, sedation, itching, and
the need for urinary catheterization. Psychological effects
such as nightmares/hallucinations and panic attacks may
also be important.
Problem specificaion
Postoperative pain management
Effectiveness
Retrieval process
Electronic search
Keywords: analgesia, postoperative pain, pain therapy,
patient controlled analgesia/PCA, epidural analgesia
English language
Year: 1966 onwards
Categorization: RCT, clinical trial, cohort study, case control
800 original
papers
and reviews
Quality control
Manual search
Contents of four anaethesia
journals
1980-1999
Reference list of review articles
identified by electronic search
410 papecs
Study selection criteria

Type of surgery:
Abdominal, major gynaecology, major orthopaedic,
thoracic
Observation period >24 h
Methods
Search strategy
We used MEDLINE (1966 onwards) to search the literature
for all English language publications concerned with the
management of postoperative pain and in particular measures of effectiveness. Keywords selected included analgesia, postoperative pain, pain therapy, i.v. PCA, and
epidural analgesia. The computerized search identified
keywords in the title, abstract, and medical subject headings
(MESH). As standard bibliographic databases label incorrectly nearly 50% of published trials, we also 'hand
searched' the full reference lists from review articles and
individual relevant papers in peer-reviewed English language journals. Finally, a hand search of four anaesthetic
journals (Anaesthesia, British Journal of Anaesthesia, Acta
Anaesthesiologica Scandinavica, and Anesthesiology) from
1980 to 1999 was performed to cross check the quality of
the retrieval method.
All publications identified by the search strategy were
categorized according to the level of evidence obtained,
based broadly on the criteria of the US Preventive Task
Force (Appendix I). Subsequent analysis was not confined
to randomized controlled clinical trials but included cohort
studies, case controlstudies, arid audit reports; that is level 2
and level 3 evidence. Case reports were not included, nor
were authors approached for raw or unpublished data. No
attempt was made to grade individual papers according to
quality. All of the studies used in the analysis were given
equal value. Data extraction was undertaken by one author
(S.D.). Figure 1 summarizes the methodology.
212 papers
Data categorization
Details of pain assessment
Pain intensity/pain relief scores using VAS and/or NRS
scales
165 papers
Synthesis of review
Combining of data
VAS and NRS scales
Intramuscular analgesia, i.v.-PCA, epidural analgesia
Pain intensity
123 papers
Epidural catheter dislodgement

23 papers
Pain relief
53 papers
Fig 1 Postoperative pain management: data retrieval flow diagram.
Selection criteria
We included articles relating to abdominal, major gynaecological, major orthopaedic, and thoracic surgery. The
shortest period of observation was 24 h. Initial observations
410
Screening of references
Accessible pain data
Pain or pain relief reported as primary or secondary end point
Dolin et al.
made in the recovery room were not included. We excluded

articles relating to paediatric, day stay, and minor surgery
and where the period of observation was less than 24 h. We
did not include any study in which a mixed or unusual
analgesic technique (e.g. ketamine, clonidine) was described. We did not include articles relating to intrathecal
opioids because it is an infrequently used technique (in a
Europe-wide survey epidural analgesia was used eight times
more frequently than intrathecal analgesia9). Neither did we
include studies of combined spinal/epidural analgesia nor
articles relating to regional analgesic techniques such as
interpleural, paravertebral, and lumbar plexus blocks for the
same reason.
Definitions
Statistics
The mean percentage reporting a given level of pain was
found by the method of weighted mean, weighting by the
number of subjects in the group.10 When patients were
grouped by analgesic technique, some studies contributed
subjects to more than one group. The presence of a few
studies in more than one analgesic technique was ignored in
the analysis, possibly resulting in a small loss of power.
Where appropriate groups were compared using analysis of
variance. The percentage of patients reporting pain was
weighted by the number as described previously and this
figure was used in the analysis rather than any other
statistical transformation. This is because our main aim was
to estimate the percentage reporting pain for the whole
population. All analyses were done using Stata 5.0 (Stata
Corp., College Station, TX).
Results
We identified over 800 original papers and reviews, 410 of
which contained data that were suitable for the metaanalysis as a whole. Papers which fulfilled our inclusion and
exclusion criteria, and from which we were able to extract
usable data on pain intensity and pain relief (several papers
had data on both) data totalled 212. Some papers contributed
both pain intensity and pain relief data. This resulted in 222
papers as follows: i.m. analgesia 45 papers (Appendix II),
PCA 73 papers (Appendix III), and epidural analgesia 104
papers (Appendix IV). Pain intensity results were obtained
from 123 papers, which included a total of 19 909 patients,
published between 1973 and 1999. Pain relief results were
obtained from 53 papers, which included 9068 patients
published between 1972 and 1998. The incidence of
premature epidural catheter dislodgement was obtained
from 32 papers, which included 13 629 patients, published
between 1975 and 1998 (Appendix V).
411
We were interested in obtaining, from the published

literature, the incidence of analgesic 'failure' after major
surgery. Defining analgesic 'failure' would involve making
a number of assumptions, and may differ between patients
and medical staff. We have simply calculated the overall
incidence of pain intensity in two categories: the percentage
of patients who experienced moderate-severe pain and the
percentage of patients who experienced severe pain at some
time during the first 24 h. We calculated these incidences for
each of the three analgesic techniques in common practice:
i.m. analgesia, PCA, and epidural analgesia.
Information was extracted from published studies, which
reported pain scores using any one of three different
measures; visual analogue scale (0-100 mm), numerical
rating scale (0-10), and verbal rating scales (mild/moderate/
severe). The different measurements have been recorded
and where studies involved comparison between drugs
using the same technique (e.g. epidural opioids vs epidural
local anaesthetics) the results have been pooled, to reflect
what happens in clinical practice, such as a mixture of drug
regimens. Where the study has compared analgesic techniques (PCA vs epidural) results have been recorded
separately under each technique.
Studies used either contemporaneous pain assessments
and/or retrospective pain assessments. For contemporaneous pain scores the worst score in the first 24 h was
used, excluding recovery room. The percentage of patients
with moderate-severe pain and with severe pain was
recorded from each study and this figure was weighted by
the number of patients in the study. Moderate-severe pain
was taken as a visual score greater than 30/100 or a
numerical score greater than 3/10 in this review, in common
with most authors. In many but not all studies it was possible
to obtain a separate figure for the percentage of patients
experiencing severe pain, which was taken as pain intensity
score of greater than 70/100 or 7/10. Only when pain
intensity scores were reported as raw data, as percentages
with moderate or severe pain, or as histograms were we able
to extract incidence data. The commonest reason not to
include pain intensity data was when pain scores were
presented as mean and standard deviation. As the pain

scores were unlikely to be normally distributed it was
impossible to obtain the percentage of patients experiencing
moderate-severe pain and severe pain. Commonly, a single
verbal score was recorded after 24 h, whereas visual scores
were often recorded contemporaneously at intervals during
the 24 h period.
Several studies reported not only pain but also pain relief.
Escape criteria such as the need for additional 'rescue'
analgesia was also reported in some studies. Most studies
reported pain/pain relief at rest but there are some scales that
combine pain at rest and on movement; these have been
analysed separately.
A number of studies reported the incidence of premature
catheter dislodgement, and as this was relevant to analgesic
'failure' this was included in the study. Occasionally the
incidence of missed segments or unilateral blocks was
reported, but this was insufficient for formal analysis.
20
1612840
u
86A
10
20 30 40 50 60 70 80 90
% with moderate pain at rest by VAS
100
10
20
30 40 50 60 70 80
% with severe pain by VAS
90
100
20
30 40 50 60 70 80
% with severe pain by VRS
90
100
20n
1612-
m m PI
o-
Mill
10
20 30 40 50 60 70 80 90
% with moderate pain at rest by VRS
100
Fig 3 Frequency distribution (numbers of papers) reporting severe pain at

rest as measured by visual and verbal scales. There were no differences
between these two methods of measuring pain.
Pain intensity
analgesic technique, the relationship with time was no

longer significant (P=0J) and the estimated fall was
reduced to 0.2% per annum (95% CI -0.6 to 0.9). The
effect of analgesic technique was highly significant
(P<0.0001), indicating that as epidural analgesia was
introduced postoperative analgesia improved over time.
The incidence of moderate-severe pain and severe pain by
analgesic technique is shown in Table 4. Epidural analgesia
resulted in the smallest percentage reporting both moderatesevere incidence for pain and severe pain, while i.m.
analgesia resulted in the highest percentage. Moderatesevere pain on movement was unreliable, because pain on
movement was not commonly reported except in studies of
epidural analgesia, with resulting wide confidence intervals.
There were no differences between analgesic techniques in
the relative numbers of studies based on type of surgery
(gynaecological, abdominal, orthopaedic, and thoracic).
We initially analysed visual and verbal scales separately.

Visual or verbal scales produced similar distributions for the
percentage of patients having moderate or greater pain
(Fig. 2). The corresponding distributions for severe pain are
shown in Figure 3. Visual and verbal pain scales were
compared using analysis of variance and there were no
significant differences between the distributions.
Table 1 shows the percentage of patients experiencing
moderate-severe and severe pain for both visual and verbal
scales, and when both scales were combined. These results
were similar for both scales and when considered together
with the analysis of the distributions in Figures 2 and 3, we
felt that it was statistically valid to regard the distributions
of visual and verbal scales as coming from the same
population. Subsequent analysis was therefore conducted on
the combined data, allowing the maximum possible number
of studies to be used.
The overall mean percentages reporting pain in the three
analgesic techniques, weighted for study size, are shown in
Table 2: the percentage reporting moderate-severe pain at
rest is thus estimated to be between 26 and 33%. Severe pain
was reported by between 8 and 13% of patients in the first 24
h after major surgery.
As part of the analysis we looked at how the incidence of
pain altered between 1973 and 1999. The analgesic
technique reported varied with year of publication
(Table 3). In the early part of the period of the analysis,
i.m. analgesia was the most frequently reported technique,
whereas in the later part epidural analgesia was the most
frequent. Between 1973 and 1999 there was a significant fall
in the overall incidence of moderate-severe pain at rest
(/><0.0001), by 1.9% per annum (95% CI 1.1-2.7). When
the relationship between percentage reporting moderatesevere pain and year of publication was adjusted for
Pain relief
Nearly all pain relief was recorded using a verbal rating
scale (good, fair, poor) and were generally retrospective, so
we have not separated the methods of recording. The results
are shown in Table 5.
Overall, between 2 and 5% of patients reported poor pain
relief and between 16 and 22% reported only fair-to-poor
pain relief. While poor pain relief was most frequently
reported by patients receiving epidural analgesia, the
numbers of papers was small with wide confidence
intervals.
Over the period 1972-1998 significantly fewer patients
reported poor pain relief (F<0.04), a decrease of 0.4 (95%
CI 0.1-0.6) percentage points per year. When adjusted for
analgesic technique the relationship was no longer significant. However, the proportion reporting fair-to-poor pain
relief was unchanged over time.
412
Fig 2 Frequency distribution (numbers of papers) reporting moderatesevere pain at rest as measured by visual and verbal scales. There were
no differences between these two methods of pain measurement.
Dolin et al.
Table 1 Percentage of patients reporting moderate-severe pain or severe pain as measured by the three different pain scales, unweighted for study size.
VAS=visual analogue scale; VRS=verbal rating scale
Mean (%)
reporting pain
Number of
studies
VAS pain score only

Moderate-severe at rest
Moderate-severe on movement
Severe
VRS pain score only
Severe
Combined VAS and VRS pain score
Severe
Range
Standard
deviation
Min
Max
64
25
31
35
44
9
26
31
9
0
0
0
100
95
44
73
9
47
39
38
13
28
29
16
0
0
0
100
78
73
136
33
78
37
41
11
27
30
14
0
0
0
100
95
73
Combined VAS and VRS pain score
Number of studies
Mean (%) reporting pain
Standard error
95% Confidence interval
Severe
136
33
78
29.7
32.2
10.9
1.7
3.7
1.3
26.4-33.0
24.8-39.6
8.4-13.4
Premature epidural catheter dislodgement

We have confined our analysis to the incidence of catheter
loss as we felt that unilateral block and missed segment
represented technical difficulties with instigating the block.
The overall mean (95% CI) incidence of premature epidural
catheter dislodgement based on 13 629 patients from 32
studies was 5.7 (4.0-7.4)%.
Discussion
How much pain is acceptable after surgery? The evidence
from this review indicates that the overall incidence of
severe pain reported in the literature is 11%. This contrasts
with the Audit Commission's (UK) recommendation that by
2002 less than 5% of patients should experience severe
postoperative pain. However, when considering a standard
of care for pain intensity case mix is important. Day surgery
pain can result in mild or no pain that can be managed by
relatively simple techniques and procedures including takehome oral analgesia and advice.11 This review was limited
to those operations after which moderate-severe postoperative pain could be expected, namely major abdominal
gynaecological surgery, major orthopaedic surgery, and any
laparotomy or thoracotomy.12 Importantly, these operations
would all be in the remit of the pain service and would
generally require postoperative analgesia by i.m. analgesia,
PCA, or epidural analgesia.
This review differs from a formal systematic review with
meta-analysis in a number of respects. We did not confine
Table 3 Numbers of published studies by year

i.m.=intramuscular; PCA=patient-controlled analgesia
Publication date
Pre 1974
1975-1979
1980-1984
1985-1989
1990-1994
1995-1999
of
publication.
Total
Method of analgesia
i.m.
PCA
Epidural
1
0
5
14
11
0
0
1
4
9
19
16
0
2
1
18
27
23
1
3
10
41
55
39
ourselves to randomized controlled trials and no attempt

was made to grade individual papers according to quality.
All of the studies used in the analysis were given equal value
as we were not concerned with the conclusion of the
individual study merely the incidences of pain intensity. We
feel that this approach is justified as we were not considering
the results of published studies but were concerned with
extracting the data from them. However, we did confine our
search to English language publication because of the
necessity to read in detail both the methods and results
sections of each paper. This might be considered as a flaw
although the large number of publications included will tend
to reduce any tendency to bias. The hand search performed
on four anaesthetic journals was designed to cross check the
completion of the electronic search. As few new papers
were picked up by this search method it was not extended to
413
Table 2 Percentage of patients reporting moderate-severe pain or severe pain, as measured by all three pain scales combined, weighted for study size.
VAS=visual analogue scale; VRS=verbal rating scale
Table 4 Percentage of patients reporting moderate-severe pain or severe pain by analgesic technique, weighted for study size. *Cannot be estimated as
numbers are too small. i.m.=intramuscular; PCA=patient-controlled analgesia
Analgesic technique
Moderate-severe pain at rest
i.m.
PCA
Epidural
Moderate-severe pain on movement
i.m.
PCA
Epidural
Severe pain
i.m.
PCA
Epidural
Number of studies
Mean (%) reporting pain

Mea
Standard error
29
45
62
67.2
35.8
20.9
4.4
2.2
1.6
58.1-76.2
31.4^0.2
17.8-24.0
1
10
22
78.0
25.3
37.9
7.5
3.6
8.4-42.1
30.4-45.4
21
27
30
29.1
10.4
7.8
4.9
1.2
0.8
18.8-39.4
8.0-12.8
6.1-9.5
All subjects
Poor
Fair-to-poor
% reporting poor pain relief
i.m.
PCA
Epidural
% reporting poor or fair pain relief
i.m.
PCA
Epidural
Number of studies
Mean (%) reporting pain relief
Standard error
38
47
3.5
19.4
0.5 .
1.5
5
17
16
1.6
3.6
5.2
1.3
0.8
0.7
12
16
19
21.3
16.7
19.4
3.5
2.2
2.1
13.6-29.1
12.1-21.3
15.0-23.7
other journals. Data extraction was undertaken by one

author, because we did not need to confer over quality of
each study, simply extract reported incidence. A degree of
heterogeneity is inevitable in a review of this type.
However, we feel that the large numbers of studies included
and the small number of differences sought will reduce the
likelihood of statistical heterogeneity. Also, we were
mindful of the dangers of over interpretation inherent in
searching for causes of heterogeneity. Indeed, it has been
suggested that over investigating heterogeneity may be
likened to subgroup analysis in individual trials.13
Nevertheless, we have simply reported incidences of pain
intensity, and refrained from formal statistical comparisons
between analgesic techniques. With respect to clinical
heterogeneity we found that the surgical case mix of the
studies used was not only very similar between the three
analgesic techniques but was also similar to that reported by
Moriarty and colleagues14 and to the case mix of the Acute
Pain Service in one of the authors' hospitals (Table 6). We
feel confident therefore that these findings mirror 'clinical
practice'.
The evaluation of pain after surgery is complex. It is
generally accepted that the visual analogue scale is more
sensitive and more accurate in representing pain intensity
2.4-4.6
16.4-22.3
1.8-5.4
3.7-6.8
Table 6 Surgical case mix of studies used in review: percent of papers

published in each surgical discipline by analgesic technique compared with
audit data. *Results of St George's Hospital Acute Pain Service audit
1998-1999 (unpublished)
Analgesic technique
Surgical discipline
General Gynaecology Orthopaedic Thoracic
i.m.
PCA
Epidural
Moriarty et al.14 (n=1660)
Audit data* (=1571)
59
69
56
69
34
13
17
6
4
22
10
12
11
14
20
18
2
27
2
13
than other single dimension pain scales. Nevertheless,

verbal rating scales (mild/moderate/severe) are widely used
clinically and have the advantage of reflecting some of the
multidimensional nature of pain. There is evidence that
visual and verbal scales are moderately well correlated.15
Other pain scores such as Magill Pain Questionnaire are
rarely used for acute postoperative pain.
Analgesic 'failure' has been described in various terms in
different studies depending on which pain scale was used.
Many studies using verbal rating scales regarded moderate
414
Table 5 Percentage of patients reporting fair-to-poor pain relief or poor pain relief by analgesic technique, weighted for study size. *Cannot be estimated as
numbers are too small. i.m.=intramuscular; PCA=patient-controlled analgesia
Dolin et al.
effective technique,22 23 the literature suggests this does not

occur in clinical practice. The rate of analgesia 'failure'
after i.m. analgesia has received relatively scant attention in
the literature; there were only 45 published articles (many
acting as control groups for other techniques) with no large
prospective studies as exist for both PCA and epidural
analgesia. Epidural analgesia is generally considered more
effective than PCA. Large prospective studies of epidural
analgesia such as Scott report 17.4% analgesic failure22 and
Stenseth reported 24-37% of patients after laparotomy
experienced analgesic failure by their criteria.25 Our review
indicates a lower incidence of moderate-severe pain and
severe pain when epidural was used (20.9 and 7.8%,
respectively) compared with PCA (35.8 and 10.4%, respectively). The epidural figures are undoubtedly confounded by
technical failures such as premature epidural catheter
displacement, which we found to have an incidence of
5.7%. Epidural analgesia does present some particular
challenges to pain services. The rate of technical failure has
been reported as high as 18.7% in the first 72 h.25 In addition
to premature catheter dislodgement, problems include
unsuccessful placement, unilateral block, and missed segments. When these problems occur on postoperative wards
there may be no back-up analgesia provided, and it may take
time for the problem to be recognized and an appropriate
response initiated.
We avoided any measures of patient satisfaction in this
review, although some studies did report satisfaction rates.
Satisfaction is complex and probably has contributions from
many aspects of postoperative care, including effectiveness
of analgesia, and perceived safety of analgesic technique
and side-effects of treatment. While a number of studies
have assessed patient satisfaction and measuring postoperative pain intensity, there was generally a poor correlation between the two. Patient satisfaction remains high
even in the presence of moderate to severe pain.17 26 27 The
reasons for this are complex. Patients appear to expect some
pain after surgery. Furthermore, in the presence of pain,
patients are apparently satisfied by the fact that their health
carers are attempting to provide pain relief even if the
results are not always successful, as judged by postoperative
pain scores. Satisfaction does not actually measure what
happened after surgery, but only how satisfied the patient
was about what happened. If patients are not aware that
excellent postoperative pain relief is achievable then they
may well be satisfied with less. Patients may not seek
complete pain relief and so self-administer PCA to only
moderate levels of pain relief.28 In addition patients may
report higher satisfaction for fear of offending those
providing their postoperative care. Measuring patient satisfaction will, it seems, nearly always show high levels of
satisfaction for pain relief after surgery, and it is not a
particularly discriminating measure of success of a pain
service.
In summary, we present a review of published data on the
effectiveness of acute postoperative pain management from
415
or severe pain in the postoperative period as representing

inadequate analgesia. In studies that have used visual scales,
scores more than 30/100 or 3/10, respectively, were the
most frequently used scores indicative of inadequate
analgesia.1718 Rarely lower scores (more than 20/100)19
or higher scores (more than 50/100)20 were used as
endpoints to define inadequate analgesia. A visual score
more than 70/100 was the most common endpoint to define
severe pain, although more than 50 has been used.21
Another group has proposed that moderate pain on verbal
score equates to a mean visual score of 49 mm, whilst severe
pain equates to a mean visual score of 75 mm.16
Nevertheless, by analysing both visual and verbal scales
separately we were able to demonstrate that, used in this
way, these two scoring systems give broadly similar results,
and can be used interchangeably.
A number of studies recorded pain both at rest and on
movement. It is unclear whether patients distinguish
between pain at rest and pain on movement. This may be
influenced by such factors as presence of persistent cough,
need for physiotherapy, dressing changes, etc. It is probable
that, when patients are asked to rate pain over the previous
4 h or at the end of 24 h, they may not distinguish between
pain at rest and pain on movement, but may give an overall
assessment. It was interesting to note that measurement of
pain on movement occurred mostly in studies involving
epidural analgesia and seemed of less concern to authors
reporting results for other techniques. There were sufficient
data to calculate an overall incidence only for pain on
movement for moderate-severe pain, but not for severe pain
alone. It seems from the literature that pain on movement
was reported relatively infrequently and the calculated
incidence of pain was associated with wide confidence
intervals. For this reason we have limited conclusions and
recommendations to pain at rest," which was available for
both moderate-severe pain and severe pain, and was
associated with narrower confidence intervals.
A number of studies report not only pain intensity but also
pain relief. Escape criteria such as the need for additional
'rescue' analgesia have also been reported in some studies.
The literature on pain relief after major surgery reports a
wide range of effectiveness of analgesic techniques. It was
unclear how to interpret the incidence of pain relief, as
opposed to pain intensity. There were sufficient studies to
calculate incidence of fair-to-poor pain relief and poor pain
relief but confidence intervals were relatively wide. The
incidences of pain relief do not match the incidences of pain
intensity, either overall or for each analgesic technique. It is
possible that the incidence of pain intensity is a more direct
measure, as pain relief will presumably vary with initial
pain intensity.
Our findings that i.m. analgesia was associated with the
highest percentage of patients experiencing inadequate
analgesia support the general view that it is the least
effective of the three techniques studied. Although using
strict criteria for administration, i.m. analgesia can be an
416
BD. Variation in postoperative analgesic requirements in the

morbidly
obese
following
gastric
bypass
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Appendix I
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United States Preventive Task Force levels of
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evidence
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Goudie TA, Allan WB, Lonsdale M, Burrow LM, Macrae WA, Grant
Level 1
IS. Continuous subcutaneous infusion of morphine for
Evidence obtained from systematic review of relevant
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randomized controlled trials with meta-analysis where
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Level 2
Harrison DH, Sinatra R, Morgese L, Chung JH. Epidural narcotic and
Evidence from one or more well-designed randomized
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68: 454-7
Hasenbos M, van EgmundJ, Gielen M, Crul JF. Postoperative analgesia
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Appendix II
and meperidine in treatment of postoperative pain. Can J Anaesth
1987; 34:462-5
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epidural analgesia the incidence of moderate-severe pain
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possible to propose reasonable targets. We suggest that
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Dolin et al.
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British Journal of Anaesthesia 89 (3): 409-23 (2002)

Effectiveness of acute postoperative pain management:

The Acute Pain Service is a relatively recent innovation,

There is evidence that pain services affect morbidity and

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Effectiveness of postoperative pain management

Audit Commission document how these figures have been

Study selection criteria

Epidural catheter dislodgement

Fig 1 Postoperative pain management: data retrieval flow diagram.

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made in the recovery room were not included. We excluded

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We were interested in obtaining, from the published

presented as mean and standard deviation. As the pain

Effectiveness of postoperative pain management

Fig 3 Frequency distribution (numbers of papers) reporting severe pain at

analgesic technique, the relationship with time was no

We initially analysed visual and verbal scales separately.

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VAS pain score only

Combined VAS and VRS pain score

Mean (%) reporting pain

95% Confidence interval

Premature epidural catheter dislodgement

Table 3 Numbers of published studies by year

ourselves to randomized controlled trials and no attempt

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Effectiveness of postoperative pain management

Mean (%) reporting pain

95% Confidence interval

Mean (%) reporting pain relief

other journals. Data extraction was undertaken by one

95% Confidence interval

Table 6 Surgical case mix of studies used in review: percent of papers

than other single dimension pain scales. Nevertheless,

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effective technique,22 23 the literature suggests this does not

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or severe pain in the postoperative period as representing

Effectiveness of postoperative pain management

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BD. Variation in postoperative analgesic requirements in the

which it has been possible to calculate the incidence of

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patients undergoing cholecystetomy. Surg Gynecol Obstet 1992;

Effectiveness of postoperative pain management

Downloaded from http://bja.oxfordjournals.org/ by guest on December 29, 2015

upper abdominal surgery. Acta Anaesthesiol Scand 1994; 38:

efficacy and side effects of morphine and pethidine by patient

Downloaded from http://bja.oxfordjournals.org/ by guest on December 29, 2015

relief after cardiac operations. J Thorac Cardiovasc Surg 1987; 93:

Effectiveness of postoperative pain management

thoracic morphine for relief of postthoracotomy pain. Anesth

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de Kock M, Gautier P, Pavlopolou A, Jonniaux M, Lavand'homme P.

Schug SA, Fry RA. Continuous regional analgesia in comparison with

Downloaded from http://bja.oxfordjournals.org/ by guest on December 29, 2015

between extradural infusion of ropivacaine or bupivacaine for

Effectiveness of postoperative pain management

Vandermeersch E. Epidural PCA with bupivacaine and sufentanil. Ada

Downloaded from http://bja.oxfordjournals.org/ by guest on December 29, 2015

References used to calculate incidence of premature

Johnson RG, Miller M, Murphy M. Intraspinal narcotic analgesia: a